Extended Venous Thromboembolism (VTE) Prophylaxis for orthopaedic patients - NHS Borders

What's new / Latest updates

Change to enoxaparin from dalteparin and the layout of the guideline.

Objectives

To provide advice on appropriate anticoagulation for patients admitted to the BGH undergoing orthopaedic surgery (hip, knee, trauma in limbs).

Audience

For use in patients receiving orthopaedic surgery at the BGH including elective and trauma patients (who are immobile or non-weight bearing).

General prescribing guidelines:

Low molecular weight heparin (LMWH)(enoxaparin/dalteparin) should be prescribed 6-8 hours post-surgery (unless there are concerns over haemostasis) and then at 18:00 the following day for a total for 7 days (i.e. only one LMWH dose per day).
Patients being discharged on LMWH should if possible be taught to self-administer (or carer taught to administer). Alternatively, ward nursing staff should confirm that community nurses can administer and that the LMWH is prescribed on a community chart by ward medical staff on discharge from the hospital.
If a patient requires community nursing services and requires twice daily dosing of enoxaparin (as per table 3) convert to once daily dosing of dalteparin (5000 units if >46kg, BMI>19 or eGFR>30ml/min/1.73m² or 2.500 units if <46kg, BMI <19 or eGFR 10 – 30 ml/min/1.73m²).
Patients who require NSAIDs (non-steroidal anti-inflammatory drugs) analgesia post-op and for discharge are prescribed etoricoxib 60mg or 90mg daily for a max of 7 days post op with proton pump inhibitor (PPI) cover. Etoricoxib does not have an antiplatelet effect.

The process for determining appropriate extended prophylaxis for hip and knee replacement follows in the sections below:

On Admission - the risk of VTE should be assessed and a score assigned to the patient.

Thrombosis risk scoring per indication:

3 points per indication	2 points per indication	1 point per indication
Acute spinal cord injury (paralysis) within last month Hip, pelvis or lower limb fracture within 1 month Multiple trauma within last month Stroke (excluding within last month)	Cancer or chemotherapy within last 6 months Obesity (BMI >30) Previous DVT or PE Thrombophilic status – known thrombophilia with history of clot	Abnormal pulmonary function, COPD, serious lung disease Age >60 years Congestive cardiac failure, MI within 1 month Current swollen legs Family history of DVT or PE History of recurrent spontaneous loss of pregnancies (x3) Immobilisation or current bed rest Inflammatory bowel disease Lower limb plaster cast or brace Nephrotic syndrome Oral contraceptive, HRT, tamoxifen, raloxifene Pregnancy or less than 1 month postpartum Protein C or S deficiency, APC resistance, positive factor V Leiden, elevated serum homocysteine, positive lupus anticoagulant, elevated anticardiolipin antibodies, antithrombin III deficiency, etc Sepsis within 1 month Significant varicose vein
High risk of thrombosis	Score > 5
Low/Moderate risk of thrombosis	Score <5

Conditions with increased risk of bleeding that require additional consideration

Determine if there is an increased risk of bleeding for the patient who may require a tailored plan and a discussion with haematology/ neurology/ cardiology:

Indications which require additional review from other specialities (anticoagulation is cautioned/ additional bleeding risks considered:

Presence of active bleeding
Concurrent oral anticoagulant use (warfarin, DOACs), platelet inhibitors (clopidogrel, aspirin, dipyridamole) (see Accordion Section - Determine the appropriate prescribing plan)
Thrombocytopaenia (platelets < 100,000)
Presence of or history of heparin induced thrombocytopenia
Haemophilia or other coagulopathy
Severe liver disease
Active peptic ulcer
Severe uncontrolled hypertension (systolic > 200 or diastolic >120)
Acute stroke within last month
CNS surgery within last 3 months
Lumbar puncture/ epidural/ spinal anaesthesia expected within the next 12 hours (consider also the timing of the removal of epidural/ spinal catheter- prophylaxis should be avoided within the 12 hours prior to these events)
Untreated inherited bleeding disorder

Review current anticoagulant and antiplatelet medicines

Plan for concurrent anticoagulants and antiplatelet medicines:

Drug and indication	Recommendation
Any anticoagulant for any indication	Stop anticoagulant whilst on LMWH Restart anticoagulant for it to be therapeutic on day 8 (Target INR to be achieved by Day 8). If on warfarin, continue LMWH until therapeutic INR. Do not prescribe Apixaban and another anticoagulant concurrently
Aspirin 75mg or clopidogrel 75mg for secondary prevention (MI/CVA) or who have had a PCI > 1 year ago	Withhold aspirin and clopidogrel whilst on apixaban. Restart once apixaban course is finished.
Aspirin 75mg or clopidogrel who have had a PCI/stent < 1 year ago	Discuss with cardiology

Determine the appropriate prescribing plan

If thromboprophylaxis is withheld or there is a deviation from this guidance the reasons must be documented in the patient’s case notes.

Extended Prophylaxis recommendations:

Patient Group	Extended Anticoagulation
Patients undergoing knee replacement surgery who score less than 5 in the thrombosis risk table	Enoxaparin (dose as per table 3) for 7 days, followed by 2.5mg apixaban twice daily to complete 14 days total post-op prophylaxis. Apixaban to commence 24 hours after last enoxaparin dose. Total amount supplied on discharge from BGH.
Patients undergoing knee replacement surgery who score 5 or more in the thrombosis risk table	As above, then continue apixaban for a further 10 weeks. Duration depends on risk of thrombosis and speed of recovery to full mobility. This will be assessed before discharge.
Patients undergoing hip replacement surgery who score less than 5 in the thrombosis risk table	Enoxaparin (dose as per table 3) for 7 days, followed by 2.5mg apixaban twice daily for 28 days to complete 35 days total prophylaxis. Apixaban to commence 24 hours after last enoxaparin dose. Total amount supplied on discharge from BGH.
Patients undergoing hip placement surgery who score 5 or more in the thrombosis risk table	As above, then continue apixaban for a further 10 weeks. Duration depends on risk of thrombosis and speed of recovery to full mobility. This will be assessed before discharge.
Patients with lower limb trauma/ non weight bearing who receive surgery who score less than 5 in the thrombosis risk table	Enoxaparin (dose as per table 3) for 7 days, followed by 2.5mg apixaban twice daily to complete 14 days total post-op prophylaxis. Apixaban to commence 24 hours after last enoxaparin dose. Total amount supplied on discharge from BGH. Enoxaparin (dose as per table 3) for 7 days, followed by 2.5mg apixaban twice daily to complete 14 days total post-op prophylaxis. Apixaban to commence 24 hours after last enoxaparin dose. Total amount supplied on discharge from BGH.
Patients with lower limb trauma/ non weight bearing who receive surgery who score more than 5 in the thrombosis risk table	As above, then continue apixaban for a further 10 weeks. Duration depends on risk of thrombosis and speed of recovery to full mobility. This will be assessed before discharge.
Patients with lower limb trauma/non weight being who do not undergo surgery	Apixaban 2.5mg twice daily for 6 weeks (or period of non weight bearing).

Determine the appropriate dose of enoxaparin

Enoxaparin dosing table for thromboprophylaxis:

Weight (kg)	Dosage in eGFR ≥30ml/min/1.73m²	Dosage in eGFR 15-29 ml/min/1.73m²	Dosage in eGFR <15 ml/min/1.73m² (including intermittent HD and CVVHD)
<50kg	20mg ONCE daily	20mg ONCE daily	Less than 5 in thrombosis risk table: Consider mechanical measures More than 5 in the thrombosis risk table: enoxaparin 20mg once daily
50-100kg	40mg ONCE daily	20mg ONCE daily	Less than 5 in thrombosis risk table: Consider mechanical measures More than 5 in the thrombosis risk table: enoxaparin 20mg once daily
101-150kg	40mg TWICE daily	40mg ONCE daily	40mg ONCE daily
>150kg*	60mg TWICE daily	40mg TWICE daily	40mg ONCE daily

*due to limited clinical evidence for prophylactic LMWH in extremes of body weight and renal impairment, all doses recommended are off label. Monitoring of LMWH assay is recommended for patients with a body weight >150kg.

Medicine Chart - Discharge Letter - Labelled Stock Supply

Prescribe appropriate medicines on medicine chart and discharge TRAK letter. Supply sufficient labelled stock of enoxaparin and apixaban for the intended course of extended prophylaxis.

Last reviewed: 30/04/2026

Next review date: 30/04/2029

Author(s): Harvey, K, Siddiqi, R.

Version: v4.0

Co-Author(s): Campbell, S, Morrison, R.

Approved By: NHS Borders Area Drug & Therapeutics Committee

Reviewer name(s): Harvey, K.

References

SPC enoxaparin

BNF

Previous NHS Borders guidelines for hip and knee thromboprophylaxis